Nursing Elites

1. You are working on a burns unit, and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?

• A. Metabolic alkalosis
• B. Hypermagnesemia
• C. Hypercalcemia
• D. Hypovolemia

Correct answer: D

Rationale: When a patient exhibits signs and symptoms of third-spacing, where fluid moves out of the intravascular space but not into the intracellular space, hypovolemia is expected. This leads to a decreased circulating blood volume. Increased calcium and magnesium levels are not typically associated with third-spacing fluid shift. Burns usually result in acidosis rather than alkalosis, making metabolic alkalosis an incorrect choice. Therefore, hypovolemia is the correct answer in this scenario.

2. You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration?

• A. Extravasation of the medication
• B. Discomfort to the patient
• C. Blanching at the site
• D. Hypersensitivity reaction to the medication

Correct answer: A

Rationale:

3. When does dehydration begin to occur?

• A. the body reduces fluid output to zero.
• B. the body increases the release of ANH.
• C. the salivary secretions decrease.
• D. the salivary secretions increase.

Correct answer: C

Rationale: Dehydration leads to a decrease in the body's fluid levels, causing the salivary glands to produce less saliva, resulting in a dry mouth. Therefore, when dehydration begins to occur, salivary secretions decrease. Choice A is incorrect because the body does not reduce fluid output to zero during dehydration; it tries to conserve fluids. Choice B is incorrect as dehydration does not directly increase the release of ANH (Atrial Natriuretic Hormone). Choice D is incorrect because salivary secretions do not increase but decrease during dehydration.

4. You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patient's most recent laboratory reports, you note that the patient's magnesium levels are high. You should prioritize assessment for which of the following health problems?

• A. Diminished deep tendon reflexes
• B. Tachycardia
• C. Cool, clammy skin
• D. Acute flank pain

Correct answer: A

Rationale: Corrected Rationale: To assess a patient's magnesium status, the nurse should check deep tendon reflexes. Diminished deep tendon reflexes may indicate high serum magnesium levels, as hypermagnesemia can lead to neuromuscular effects. Tachycardia, cool clammy skin, and acute flank pain are not typically associated with high magnesium levels and are not priority assessments in this situation.

5. A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?

• A. Encourage oral fluid intake.
• B. Connect the client to a cardiac monitor.
• C. Assess urinary output.
• D. Administer oral calcitonin (Calcimar).

Correct answer: A

Rationale: The correct answer is to encourage oral fluid intake. With a serum calcium level of 14 mg/dL, the client is at risk of hypercalcemia. Encouraging oral fluid intake helps to promote hydration and can help prevent further elevation of calcium levels. Connecting the client to a cardiac monitor (Choice B) is important but not the first priority in this situation. Assessing urinary output (Choice C) is relevant but does not address the immediate concern of high serum calcium levels. Administering oral calcitonin (Calcimar) (Choice D) may be a treatment option later, but the first step should be to address hydration.

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